Transcript Neurology
Neurology Elisa A. Mancuso, RNC-NIC, MS, FNS Professor of Nursing Peripheral nerves – Not completely myelinated @ birth. • ↑ Myelinization = ↑ Coordination 1st Gross motor function then fine motor Primitive reflexes disappear by 5 months. – Moro, Fencing, Step • Primitive reflexes evolve to meaningful movements • Reappearance/persistent reflexes – Neurological disease Assessment • • • • • • Cognitive – – √ Appropriateness, speech Gross and fine motor– √ Strength, coordination, gait Sensory– √ Reflexes, pain, temperature Cranial nerves I-XII– √ Motor & sensory Developmental milestones– √ Delay or deviation from expected milestones. Obtain accurate history! – √ family/genetic – √ any past head injuries or trauma at birth Glasgow Coma Scale • Eye Opening • • • • Spontaneous To Verbal Stimuli To Pain Only No response 4 3 2 1 • • • • • Coos & babbles/Oriented Irritable cries/Confused Cries to pain/Inappropriate words Moans to pain/Non specific words No response 5 4 3 2 1 • Verbal Response • Motor Response • Moves Purposely/Obeys commands • Withdraws to touch/localizes painful stimuli • Withdraws to pain • Decorticate posturing/Flexion • Decerebrate posturing/Extension • No response 6 5 4 3 2 1 Intracranial Pressure (ICP) Etiology ↑ ICP 1. Mass • Brain tumor, head trauma 2. Generalized brain edema • Hypoxia, encephalopathy 3. ↑ Blood Volume • IVH, obstruction of jugular veins 4. ↑ CSF production• Meningitis Signs and Symptoms • Differ according to developmental level 1. 2. 3. 4. 5. 6. 7. Infant Poor feeding or vomiting Irritability Lethargy Bulging Anterior Fontanel ↑ HC High pitched cry Sun setting sign√ Eyes deviated downward Signs and Symptoms 1. 2. 3. 4. 5. 6. 7. Child HA Diplopia Mood swings Slurred speech Papilledema (48 hours of ↑ICP) Altered LOC N/V especially in AM 1. ↑ pressure from lying flat Therapy • • • • • • • – – – – – – Maintain Patent Airway Supine & ↑ HOB @ 30 Avoid Prone & head turned to side ↓ venous drainage and ICP Avoid CO2 retention CO2 = Cerebral vasodilatation blood flow and ICP Hyperventilation = ↓ CO2 Cerebral vasoconstriction ↓ blood flow & ↓ICP √ for cerebral hypoxia & ischemia If Pt mechanically ventilated only suction PRN! Therapy • ICP monitoring – Catheter in ventricle – √ pressure in brain. – Glasgow Coma scale <7 • Manitol – Osmotic diuretic Unconscious Child • Head trauma, infection, ICP, tumor • √ LOC – ∆ = earliest indicator of ∆ in neuro status! – Lethargy • √ Pupillary response – Fixed and dilated pupils • MEDICAL EMERGENCY!!! • ↑ pressure on oculomotor nerve • √ VS =↓ HR ↓ RR ↑ BP ↑ Temp Nursing Interventions • • • • • • • ↓ ICP & Maintain ABCs Turn and position q2H Passive ROM Don’t leave on affected side > 30 min Seizure precautions Assess skin Thermoregulation (↑ temp can ↑ICP) Nursing Interventions • Eye care – Artificial tears – Cover to prevent corneal abrasions • Mouth care – Tooth brushing – Dental Care • Incontinence – Foley care – May need suppositories to stimulate BM Nursing Interventions Nutrition • Tube feedings • NGT- Short term • PEG- Gastrostomy- Long term • TPN – Broviac – √ Labs, Glucose, LFTs, Neoplasms • High incidence in 5-10 years old • Prognosis is best – when tumor is completely removed • >60% found in – cerebellum and brain stem Signs and Symptoms • • • • • • First cardinal sign = ↑ ICP HA Irritability Projectile vomiting Personality changes Location/size of tumor – Focal Affects (Behavior, Speech) – Cerebellar tumor = Ataxia Glioblastoma (Astrocytoma) • Tumor of brain or spinal cord (astrocytes) • Most common brain tumor in children • 75% survival rate Signs and symptoms • • • • • • • • Depends on location of tumor Headache Ataxia Eyes deviating (cover/uncover test) Hemiparesis + Babinski Staring spells ↑ ICP Diagnosis • Complete Neuro exam & cranial nerves • CT scan, MRI, Pet Scan Treatment • Chemotherapy • Radiation • Surgery – Retain as much viable tissue as possible! Nursing Interventions • Pre-op: Prepare child and family – Assess developmental milestones – Shave all/part of head – Extensive dsg with multiple drains • Post-Op – – – – – – – – √ LOC & Glasgow Coma Scale √ VS √ Infection Restrict fluids post-op √ I & O External shunts/drains/monitors (√ for ICP) Increase HOB slowly- No trendelenburg! No Narcotics = ↓ cerebral functioning Seizure Disorder • Epilepsy is recurrent seizure activity – Does not occur with a known cause i.e. infection, tumor • Seizure is excessive discharge of neurons. • Status Epilepticus – Prolonged or recurrent seizures – Not regaining consciousness >30 minutes Etiology • • – – – – – – • Primary Linked to genetic predisposition Include febrile, absence and benign seizures Early infancy from birth trauma or congenital defects Secondary or symptomatic seizure A temporary or permanent structural or metabolic abnormality. Cerebral lesions, malformations, metabolic disorders and hypoxia. Late infancy and early childhood from acute infections – meningitis. Idiopathic – Most common = >3 years 50% of seizures. Diagnosis • • • • • • Family Hx & Hx of symptoms – Behavior before, during and after seizure – √ Infection or metabolic causes – √ trauma, tumor, malformation – Serum Calcium, Glucose, & Magnesium Any predisposing illnesses/fever LP CT scan, MRI √ Labs Electroencephalogram (EEG) – Measures voltage in brain – Sharp waves on EEG = Epilepsy – ↓sensory stimulation during exam Classification of Seizures Generalized • Both cerebral hemispheres and ∆ in LOC • • • • Tonic-Clonic Absence Myoclonic Atonic Partial • One hemisphere affected & ∆ in LOC • Symptoms occur on one side of body • • • Partial Simple partial Complex partial Generalized Seizures 1. • • • • • Tonic clonic Aura LOC Tonic phase (10-20 secs) Clonic phase (>30 sec) Post-ictal State Generalized Seizure 2. • • • • • • • Absence seizure “petit-mal” ↑ Incidence btwn 4-12 years RT brain immaturity Usually cease at puberty Brief LOC may be mistaken for daydreaming Minimal or no alteration in muscle tone Sudden arrest of activity with no memory of event Lasts 5-20 seconds up to 20 times/day Partial Seizures 1. • • • • • • • Simple partial Localized motor symptoms Somatosensory and autonomic symptoms Unilateral hand or 1 side of body No LOC! Eyes deviate toward opposite side Jacksonian Sylvian/Rolandic Partial Seizures 2. Complex • Psychomotor seizures-most common • Age 3-adolescence • Period of altered behavior & repeated purposeless activities • Last 5-10 minutes • Aura • Lip, smacking, chewing, drooling • May yell out, inappropriate behavior Status Epilepticus • • • • Medical emergency Prolonged or recurrent seizures Not regaining consciousness >30 minutes Most common cause • • • • LOC can last hours or days Maintain airway Will most likely be intubated Ativan (lorazipam) – Sudden withdrawal of anticonvulsant meds – Quicker onset & longer acting – Less respiratory depression than valium Medication Therapy • • • • • • Controls symptoms Prevent seizures or decrease # & activity Raise the seizure threshold Decrease responsiveness to neurons Loading & maintenance doses Phenobarbital (luminal) – Therapeutic level 10-40 mcg/ml √ respirations can cause respiratory arrest! • Dilantin (phenytoin) – Therapeutic level 10-20mcg/ml. – SE hyperplasia of gums! Medication Therapy • Tegretol (carbamazepine) – Therapeutic level 4-12 mcg/ml– Monitor LFT’s! Hepatotoxic. – SE neutropenia √ WBC’s! • Valproic Acid (depakene) – Therapeutic level 50-110 mcg/ml– Monitor LFT’s! Nursing Interventions • • • • • Monitor serum drug levels Seizure precautions – Padded bed rails – O2 & Suction Teaching plan – Parents, Pt, School, Sports, Community etc. – Type of seizure – Medications & SEs Med alert bracelet Protocol for discontinuing seizure meds: 1. Pt should be seizure free for 2 years 2. Normal EEG 3. Slowly taper doses 4. EEG’s Q 6 months Meningitis • Bacterial meningitis 10-15% mortality rate • Acute inflammation of the meninges – Infection: URI, OM or sinusitis – Bacteria enters CNS/brain via nasal cavity, sinuses. – HIB, Group B strep, S.pneumoniae and Neisseria meningitides • N. Meningitides is most invasive disease. – 13 serogroups – Vaccine only covers A,B,C,Y and W-135 Incidence • • • • • • • ↑ Risk <1 year of age and >15 yrs Deficiencies in terminal complement URI HIV Asplenia Crowding Smoking or passive exposure Clinical Signs • • • • • • • • • • • Depend on age and organism Nucchal Rigidity “stiff neck” Brudzinski’s sign Kernig’s sign Abrupt onset fever and chills Vomiting & No Nausea HA Seizures Irritability Anorexia Petechiae and pupura = Sepsis – disseminated disease Diagnosis • • • • CBC with Diff BC NP/Pharyngeal cultures Lumbar Puncture LP – √ CSF color, consistency, pressure of fluid. – Sterile procedure – √ Complications; • Infection, bleeding, spinal fluid leak, • Hematoma, Spinal HA CSF Fluid Analysis • Clear, cloudy or bloody • Bacterial or viral meningitis – ↑ Protein – ↓ Glucose – WBC (PMN cells) • • • • Gram stain- +/Culture-identifies organism √ pressure >15 = ↑ ICP ↑ Blood = ↓ skill or traumatic tap Contraindications to LP • ↑ ICP– Need CT scan. – If LP done fatal herniation can occur • Bleeding disorders • Overlying skin infection (Staph/MRSA) • Unstable patient Therapy • Respiratory isolation right away! • Antibiotics 2-3 immediately!!!! – Meningitic dose (2x usual dose) – Cephalosporins and Ampicillin • Dexamethasone – ↓ inflammation • Phenobarbital – ↓ seizure activity • Mannitol – ↓ brain edema Nursing Interventions • • • • • Keep HOB >30% Quiet environment Frequent neurochecks & VS Maintain Isolation Prophylaxis medication = Rifampin – Persons in close contact – Urine turns orange and stains contact lenses Reyes Syndrome Acute Toxic Encephalopathy • ↑ Incidence with 6-11 years & virus infection • (flu/varicella) • + Relationship when treating fever with ASA • NH4 accumulates and builds up urea → – Brain edema, necrosis of neurons and cell death – Fatty infiltration of liver cells, kidney and myocardium – Impaired hepatic, renal and cardiac function Signs and symptoms • • • • • • • • • A history of preceding URI or chickenpox Nausea and vomiting x 24 hours/intractable Mental status changes Lethargy Confusion Combative behavior Loss of consciousness or coma may develop Seizures Hepatomegaly Diagnosis • • • • • ↑↑ LFT’s 2x normal Prolonged pt/ptt ↑↑ NH4 4x normal Palliative Support ↑↑ Mortality if pt is in coma = 40% Cerebral Palsy • Impaired neuromuscular control – Abnormality in cortex, basal ganglia and cerebellum • Brain injured area determines type of neuromuscular disability • Non-progressive Etiology • • • • • • Developmental anomalies Infections Toxins Cerebral trauma Hypoxia Vascular occlusion RT IVH Clinical signs • • • • • • • • Abnormal muscle tone: hyper or hypotonicity Impaired coordination and motor function Delayed gross motor development Abnormal postures Persistent primitive reflexes Spasticity or uncontrolled movements Seizures Sensory impairments Classifications Spastic • • • Most common with cortex involvement. Muscles very tense with any stimulus Sudden jerking movements • • Injury at basal ganglia. Slow, writhing, uncontrolled, involuntary movements involving all extremities Dyskinetic Classifications Ataxic • Cerebellum affected. • “Clumsy” characterized by loss of coordination, equilibrium and kinesthetic sense Rigid • Rare form with poor prognosis. • Rigidity of flexor and extensor muscles. • Tremors at rest and with movement Mixed Therapy • Early recognition and intervention is goal • Maximize child physical abilities – (Child intellectually intact) • Multidisciplinary team approach- – PT, OT, Neurologist, Orthopedic surgeon, RN, social worker • Family support & community via UCP • Treat symptoms – Baclofen pump- skeletal muscle relaxant • Increase locomotion, communication and self-help • Correct defects – – Contractures or spastic deformities Braces Retinoblastoma • • • • • • • • • • Most common congenital intraocular tumor 60% non-hereditary and unilateral 25% genetic & bilateral 15% genetic & unilateral Red inflamed eye. Persistent redness, irritation & itchy Leukokoria Loss of red reflex Strabismus-25% present Glaucoma Therapy • Genetic counseling • Early stage – Radiation or cyrosurgery • Late stage – Radiation, Chemo – Enucleation – Fit with prosthesis in 3 weeks • 90% survival rate • Unaffected eye is fine!